PTCB - Chapter 14 - Financial Issues - Key Concepts

Financial Issues
- Third party programs are simply another party besides the patient or the pharmacy that pays for some or all of the cost of medication: essentially, an insurer.
- A pharmacy benefit manager (PBM) is a company that administers drug benefit programs for insurance companies, HMOs, and self-insured employers.
- Co-insurance is essentially an agreement between the insurer and the insured to share costs. One aspect of it is the requirement for patients to co-pay a portion of the cost of prescriptions.
- The amount paid by insurers for prescriptions is not equal to the retail price normally charged, but is determined by a formula described in a contract between the insurer and the pharmacy.

Third Party Programs
- Prescription drug benefit cards contain necessary billing information for pharmacies, including the patient's identification number, group number, and co-pay amount.
- HMOs usually will not cover expenses incurred outside their participating network and often require generic substitution.
- POSs often partially reimburse expenses incurred outside of their network and usually require generic substitution.
- PPOs usually require generic substitution.
- Workers' compensation is compensation for employees accidentally injured on the job.
- Medicare covers people age 65 and over, disabled people under age 65, and people with kidney failure.
- Medicaid is a federal-state program for the needy.

Online Adjudication
- In online adjudication, the technician uses the computer to determine the exact coverage for each prescription with the appropriate third party.
- When brand name drugs are dispensed, numbers corresponding to the reason for submitting the claim with brand name drugs are entered in a DAW (dispense as written) indicator field in the prescription system.

Rejected Claims
- Many prescription drugs plan have age limitations for children or dependents of the cardholder.
- Most third party plans require that most of the medication has been taken before the plan will cover a refill of the same medication.
- Many managed care health programs require mail order pharmacies to fill prescriptions for maintenance medications.

Other Billing Procedures
- When a claim is rejected, the pharmacy technician can telephone the insurance plan's pharmacy help desk to determine if the patient is eligible for coverage.
- Claims for disease state management services can be submitted using a paper system and often require follow up.